Cancer Caring

Article Abstract

Editor’s Note

Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is in the private practice of adult psychiatry, specializing in adaptation to illness. He is author of the paperback book Cognitive Therapy: A Practical Guide (W.W. Norton & Company, 2003). In addition, he worked in an outpatient oncology office from September 1997 to February 2009 helping cancer patients adjust to their disease.

Dr Schuyler can be contacted at deans915@comcast.net.

Cancer Caring

Cancer patients in the 21st century typically are treated by an oncologist. Unrelated medical problems are in the province of an internist or a family physician. Reproductive organ problems or menstrual-related issues in a woman are handled by a gynecologist. When the brain or spinal cord is at issue, a neurologist is often called in. When the digestive tract is involved, a gastroenterologist is part of the team.

When surgery is called for, the appropriate surgeon is found. When radiation is the treatment, there is a radiation oncologist. Which of these team members is the appropriate person to speak to about adjustment to cancer? What if there is undue anxiety? What if the changes precipitated by cancer lead to major depression?

Someday, it is my hope that there will be a psychiatrist (or psychologist) attached to the team providing care for the patient with cancer. My "data" consist of the many patients who have taken the opportunity offered to them to speak with me about cancer and its emotional consequences.

Instead of a pattern consisting of a single consultation, some patients form a relationship with the psychiatrist providing care. And then they may call on that relationship again and again as the course of their cancer dictates.

Ms A was referred to me by her family doctor. I saw her 5 times over a 12-month period. No two visits were close together. She called when she thought that I could help her deal with a problem. Our relationship was ongoing, although her visits were sporadic.

CASE PRESENTATION

Ms A was 50 years old when we met, but her medical history belied her years. Over a 10-year span, she suffered a brain aneurysm, recurring colon problems, a heart attack, kidney stones, and spinal disc disease. There were several surgeries, both diagnostic and therapeutic. She survived it all by maintaining a Herculean sense of will and motivation.

Then, 2 months before we met, she was diagnosed with breast cancer. It seems cruel to say that this was the "straw that broke the camel’s back."

Born in Chicago, Illinois, she met and married her husband in Dallas, Texas. They had moved to Charleston, South Carolina, 20 years ago. Married for 25 years, they had 2 adult daughters. Ms A taught high school for 15 years; her husband practiced law.

Throughout her decade of serious medical illness, Ms A had managed to take "one day at a time." Her attitude was the envy of her many friends. Recently, however, she began to experience real anxiety before bed each night. It was this complaint that led to her referral to me for treatment.

Her mood featured a combination of sadness during the day and anxiety at night. She suffered from disrupted sleep. Her medical conditions as well as her cancer made attribution difficult for her diminution in energy as well as her constant fatigue. My working DSM-IV diagnosis was adjustment disorder, with mixed anxiety and depressed mood (309.28).

PSYCHOTHERAPY

During the intake session, I explained the cognitive therapy model to her. I emphasized the power of the mind to create anxiety. I stressed that the meanings assigned to events were provided by individuals, not by situations. I reminded her of how effectively she had approached a series of difficult events over the previous 10 years.

She returned in 2 months. "I learned to see it differently the last time I was here, and it allowed me to sleep," she said. She felt more in control of her emotions. She was now in the midst of a difficult chemotherapy regimen for breast cancer. She spoke about trying to predict the future, but when I challenged her, she retreated quickly, saying: "I guess no one knows what’s over the next hill, least of all me."

The trigger for her third visit was her mother’s statement: "I’ m afraid that I’ ll lose my child." We focused on "mindset"—her mother’s and her own. She brought up pessimistic views of other family members—all liberally offered to her. When I suggested that no one could really know what lies ahead, she switched to telling stories of boosting the morale of fellow cancer patients during chemotherapy treatments. Her methods were innovative, and feedback indicated that they were successful. I told her that knowing how to help others might offer real clues to helping oneself.

I next heard from Ms A 3 months later. She was frustrated by the lack of sensitivity she had perceived in some of her providers. Her current treatment regimen featured radiation. She saw treatment as "unending" and found it hard to picture a time when she would be well. We focused together on what she could do to help herself. Evaluating her care was useful if she planned a change, but there was no such prospect. Therefore, there were more important elements on which to focus: for example, how to plot a stress-free course for herself.

When I last saw Ms A, it was 6 months after our last visit. She had wanted reconstructive breast surgery, and it had finally occurred. She anticipated feeling good and being more in charge of herself. She had not expected that she would "fall apart."

It seemed to me to be a loss of perspective in someone who had steadfastly maintained it through unbelievable turmoil. She had reframed the desirable outcome as a "reminder" of all she had been through. The result had been demoralization. We reviewed her realistic options with regard to thinking about this latest turn of events. She left my office in decidedly better spirits than when she had come in.

DISCUSSION

Ms A has what athletes call "mental toughness." She has consistently proven herself capable of finding a way to deal with a series of demanding physical problems and treatments. I expect to see her again, but not because she has failed. Rather, she has learned to use occasional sessions to recalibrate her adjustment. Her success is a tribute to the power of what a thoughtful and hard-working person can do to deal with medical illness.

Prim Care Companion J Clin Psychiatry 2010;12(3):e1-e2

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